Ladies and gentlemen, I hope you're enjoying your lunch, and please continue to eat. I guess I would first like to start off by saying what an incredible morning with this accost. I wanna thank David Parker, especially Sanjeev. The job that our teams did together to put together an entertaining and thought-provoking morning was incredible. I think for those of you that are new to Anna, I think you now realize that one of the things that makes us different, right? We don't do any primary and specialty day. We don't do any primary papers. We feel like you can get that elsewhere. This is the one time you get. We try to take the gloves off a little bit, and we're a pretty close-knit family, and I think you can see that coming through in the culture, and just am very grateful for Issacost, and in fact, maybe I tip my cap a bit to Issacost for winning many of those debates this morning, so well done, guys. That was great. One of the great pleasures that you get to do as president of Anna is select the Anna Innovation Lecture. It is part and parcel to everything that we are. You may know this already, but Anna was a little bit of a countercultural organization when it began back in the early 80s when people like Steve Burkhardt and Jim Esch and Steve Snyder would get together because they were a little bit shunned by the establishment. This was back in the days, and some of you in the audience remember when the arthroscope was the tool of the devil, right? And so it was a little bit hard to break through in some of the traditional organizations, and those three said, look, let's go out and find this. They were often called cowboys. Many of you, even the Issacost members, remember these days when you were cowboys. Tom Sampson's in the audience. One of the founders of hip arthroscopy is gonna be talking to us later today. He knows about what it was like to come to a hip group and talk about the arthroscopic approach to hips when this was just not something that was accepted in many organizations, and so I think that is sort of a place that we've been. As Anna, you may know this, but our very structure has an overarching innovation guru and czar, if you will, now. Jason Dragoo runs that for us at Anna, and he is in charge of overseeing the innovation part of every aspect of our organization. With that, a few years ago, we decided that this would be what we would highlight, and so the president gets to select the Anna Innovation Lecture, which highlights an individual that has made great strides and paths. For me, I could choose a number of people for this honor, but for me, one of the gentlemen that has been just incredible in many areas, as you will soon see, is Pascal Boileau. Pascal is from Nice, France. He trained with Gilles Walsh, but he also did two American fellowships, including one with ESCA as he came through, then went back. He's taught us many things, and you'll see. Instability, rotator cuff, arthroplasty, three-dimensional evaluations, and patient-specific planning. You're gonna see that today. Pascal was kind enough to accept this lecture opportunity, and I felt bad. Last year, I was supposed to be at the Nice course with him, and the day I was supposed to go, they made me get a COVID test. I felt fine, and I was COVID positive after dodging it for two years, and I couldn't go, and so I had to call him at the last minute. He was very gracious about it. We're excited to get back there. This week, as we were putting things together, I called to see if we could have dinner together last night, and unfortunately, he's had a death in his immediate circle and family, and so the funeral is actually today, so we send him our prayers and our support, but typical of Pascal, in spite of the grief and the process that he's going through, he still found a way to narrate this talk because it was very important for him. He wanted me to tell many of his fellows who are in the audience a great hello and a great hug, and to those of you that he was going to meet today, he wanted to send along his sincerest apologies. As you can imagine, this is the last thing he should be worrying about right now. We're very grateful to him, and to find time in the last 48 hours to narrate this video that you're about to see, I've already seen it. It is simply excellent, so I hope you'll join me, and we are recording this, so if you don't mind, join me in a round of applause that I'll be able to send him in our support for Pascal Boileau in the 2024 Anna Innovations Lecture. Good morning, everybody. It's a pleasure, and of course, a great honor to present this talk on innovation in shoulder surgery. So that's my disclosure, and for me, everything started in Lyon with my fellowship with Gilles Walsh in the 90s, and I would like to go through these four chapters with you, innovation in arthroscopy, arthroplasty, fracture, and software. So let's start with arthroscopy. Everything started when I attended the San Diego shoulder course in 1990, and I met Jim Esch and many other great arthroscopists, and when I came back in France, I started to practice a lot of arthroscopy, and I developed some new techniques like the arthroscopic bicep stenodysis with interference glue, as you can see here, but basically, I was interested in the fact that we could discover pathology, and one of the pathologies that I discovered was the hypertrophic elongate of the biceps, which is the cause of stiffness and pain in the shoulder, as you can see, and this is a cause also of subluxation and cleavage of the subscapularis, and by doing a tenotomy or tenodesis, you can really solve this situation for the patient. Another situation, pathology that I have to face was the SLAP2 lesion. I was with Steve Snyder when he described this pathology, and when I came back, I was repairing a lot of SLAP2 until I discovered that my patients were not doing so great, and I proposed to do a bicep stenodesis, in this case, to solve the problem of pain. Another pathology that I discovered was the UPS, the unstable painful shoulder. These are patients who have a subtle instability of the shoulder, and when you discover some cleavage of the labrum, some distension of the capsule, and you can save the situation by doing a bank out repair with a capsular shift. Also, I described a technique, which is the weaver done that I modified with a piece of bone of the acromion and with a double button, but I had to operate a lot of instability of the shoulder, and I described this technique, which I call the TOTS, the temporary outside traction suture, which is nothing, you see. You just put a cannula, you take the hook, and you place a stitch at five o'clock, and then you put the suture outside the cannula, and your assistant is pulling on the suture, which put the labrum and the capsule under tension and allows you to put another stitch or two other stitch lower, and by doing this, you do a south to north capsular shift in addition to the bank out repair. Then, I follow my patients, and I have some recurrence with the arthroscopic bank out, so with Frederic Balck from Canada, we examine a series of 134 patients, and we end up with a score that we call the instability severity index score, which is here, you see, where you take into account the age of the patient, the level of participation to sports, the practice of contact of force overhead sport, the shoulder applexity, and of course, the body lesions, and these 10-point scores, in fact, allows you to find that the patients with more than three points have a high rate of recurrence with an arthroscopic bank out, and this was a real advance for us for the indication. Then, we try to do better, and in addition to the bank out, to do something more, and this is where we describe this arthroscopic bristol, where we took the coracoid process, and then we shape it, and we place it into a socket, and we fix it with an interference screw, so you get the sling effect, and this, of course, is not for patients with more than 10% of glenoid bone loss, but what we did, basically, is that we described and we developed a new technique for arthroscopic latarje, and this technique is a guided and safe procedure. Why? Because we perform the glenoid drilling from posterior to anterior using a guide, and we developed this guide to make it safe because you stay intra-articular, number one, and number two, you are sure to be parallel with the trajectory of the K-wire, to be parallel to the glenoid surface. Number two, we use and we develop specific instruments, we call the subscap spreader to make the split of the subscap to make it safe because one spreader is coming from posterior, but the other is coming from anterior and act as a retractor to protect the brachial plexus, which makes the procedure safe. In addition, we developed the suture button fixation, and this was the result of a complication, of course. One day, I had a fracture of the coracoid process, and I had to fix it, and the piece of board was too small to be fixed with a screw. That's where I get the idea of developing a suture button fixation, and later on, I develop a specific button with a Smith and a few company. And as you realize, when you have two points of fixation, one in the front, one in the back of the shoulder, this is like a bolt, and a bolt is mechanically superior to one or even to two screws. Then what we realized that if you really want to have a bolt, you need to tension the suture, and that's where I get the idea of developing a tensioner, a suture tensioner. And then I defined that you should put 100 newtons of tension three times for removing the suture creeping, for knot tying, and finally, for getting the bolt compression. And by doing this, you can get more than 95% of bone graft healing. Also, you can see the remodeling and the nice positioning of the bone graft when you do use this kind of technique. Now, we have more than 10 years follow up with this technique. You can see that there is no limitation of motion if you do it correctly. And this is really a bolt that we create by doing this operation. Now, if I have only one message to give to you, and for you to remember of this talk in this one, please abandon the screw. You can do the latarge open. There is no problem with that. I don't pretend that everybody should do a naturoscopic latarge. Do it open if you do it well, but stop your screws and try the buttons. You will see that it works. You obtain the good fixation, and it allows the remodeling of the bone block without the complication and the drawbacks that we have seen in the past with the screws. Regarding the cuff repair, we developed this technique of the tension band where you put a reverse matrix stitch, and then you put lateral anchor. And by doing this, you cover the footprint, and we publish our results. Initially, it was 75% of tendon healing. And that's why we continue to use this technique, very simple, for small and medium tears, which are not delaminated. We were facing the problem of the massive irreparable cuff tear, and the biceps was found to be a major cause of pain. That's why we describe this biceps tenotomy and tenodesis. And you see, even though the radiograph can look ugly, this patient is still happy 15 years after this simple biceps tenotomy under arthroscopy. So what I want to emphasize is that the results of biceps tenotomy have been published by myself and by Gilles Walsh. And you can see that the constant score is 67 points, which means more than 85% with the adjusted constant score. And there is only less than 10% of conversion to a reversal arthroplasty at minimum 10 years follow up. This means that this operation works and is just fantastic. And if we realize that when you have massive irreparable cuff tear, there are two kinds of massive cuff tears. The one where you have a functional shoulder, which means there is the pain mainly, and the elevation and external rotation is possible. Then you can do this operation, the biceps tenotomy. If you want, you can do a partial repair. You can do a transfer in addition if you want, a tissue patch, a balloon, or superior capsular reconstruction. But if your shoulder is non-functional, which means you have definitive muscle imbalance with your massive cuff tear, there is only one thing that works for psoroparalysis. It's the reverse, the reverse prosthesis. The transfer is for isolated loss of external rotation and the reverse plus the transfer is when you have a clear patient with combined loss of elevation and external rotation. This is very important to understand this, the definitive kind of psoral paralysis of a shoulder in the vertical plan, in the horizontal plan with the hilar, or in the combined plans with the clear. Let's talk now about the adventure in shoulder arthroplasty. Everything starts with Charles Nieuw, we know that with the monoblock prosthesis in the 50s, then you in the 85-90s you have the modular prosthesis and we came in 1990 with a modular and adaptor prosthesis. Why did we do that with Gilles? The reason is that we observed that we were not able to restore the retroversion, the inclination and the medial and posterior offset. This was one of the first papers that I wrote. This was the three-dimensional geometry of the proximal numerus and we have to develop this specific prosthesis to be able to restore the anatomy of the proximal numerus. This prosthesis that we call equalis, which means equal in Latin, was both modular and adaptable and we were lucky to have a group of friends as you can see with Christian Gerber, Daniel Mollet, Christophe Lévin, Daniel Goutelier and others and we were able to follow these patients operated with this prosthesis and we organized the first meeting in Nice in 1996 where we reported the results of 400 patients operated. Then the prosthesis was made with this version uncemented and was crossing the ocean to be implanted in the USA and we did our first one-year workshop in 1998 in Chicago to develop, to spread this prosthesis among the USA. And you can see that even though the prosthesis was implanted early in 1991 for this patient that I followed for more than 20 years with many others, the results have been fantastic and are still fantastic, sometimes despite a glenoid losing, but that's another story. And we have success, but we have also failures and we just tried to have a glenoid fixation with metal back but we failed and we have to abandon this prosthesis. We reported all our results in another meeting in 2001 in Nice where we followed 200 shoulder prosthesis with minimum 2 to 10 years follow-up and this we learned a lot with this study. Then starting in 2000, the adventure of the equalist reverse prosthesis starting from the Gramont prosthesis and this was a big advance compared to the hemiartroplasty that was the only solution that we had in the 90s. And this patient was always asking me why did you put the reverse prosthesis on my right side? And I kept telling him that we didn't have the reverse prosthesis at that time. Then the prosthesis was approved by the FDA in 2006 and some of our former fellows like Suman Krishnan and Brad Edwards were the guys who spread the knowledge and the practice in the USA. 2006 was also the year I developed, I started the bio-RSA, which is as you see a bony increased offset reverse shoulder arthroplasty, which allows you to correct the inclination, the retroversion and to lateralize. And this was a big advance because this lateralization of the glenoid was able to increase the motion in the vertical plan of course as you can see, but also in the horizontal plan. The further you go lateral with bone or with metal according to Frankel, the more you go lateral, the more you gain motion in elevation, in abduction, but also in external and internal rotation as you can see on this animation. So this was a big advance with the understanding of this prosthesis. And today when you have a prosthesis, a patient like this, where I did a reverse bio-RSA on one side and an anatomical on the other side, you can see that I did the two prosthesis in the same session and at six months this patient has the same motion on both sides just because we understood so much more since all the years. But not all patients are doing great. You see these patients have a good elevation, but she's not very happy. And why she's not happy? Because as she showed to me, she has to put the elbow up, she has a dropping arm, she cannot drink a glass of wine or water, she cannot comb her hair, she cannot dress, she cannot do many things, she cannot hold the phone. And this is why we developed this technique of making a transfer of the latissimus dorsi or the lepiscopal in combination with the reverse for this kind of patients. Later on in 2013, we came with a new prosthesis which was convertible and on-lay and with a group of friends we were able to develop this new prosthesis. Then in 2020, we developed a short-stem inlay convertible prosthesis that was both anatomic and reverse and again, the adventure was continuing in the USA. We also explore some new material like pyrocarbon for the inspired snooker ball, but also for the hemipyrocarbon which is now approved in the USA and which is a very nice solution for young people with arthritis where we don't want to implant a glenoid prosthesis. The fracture adventure was something also very important for me. Initially, there was only the hemiarthroplasty for fracture and I did a CT scan to my patients and what I observed that there was migration, posterior migration of the greater tumority and it became very obvious that this was because there was too much metal in the prosthesis. So this was not difficult to understand that if you have less metal and more bone, you could obtain a better bone healing and better result. This is why we describe also the technique with the four-circlage and two-tension band and also using double suture-knit knot which makes a very strong construct for these patients. The same prosthesis, the same kind of prosthesis with less metal and more bone was developed for the reverse prosthesis and today we have a convertible fracture stem which is both anatomic and reverse and that can be fixed not with cement but with distal and proximal screws. Regarding fracture, something very important for me that I developed and it's for me an innovation is the Equalis iron nail. This nail is a short nail. It's straight. It's small. It's introduced not in the tendon but in the muscle, so in the human head and this is very important because it allows you to do a percutaneous approach for a two-part fracture. You see this lady is 1991 year old and she is only one week after the surgery and she pushed on her upper limb to stand up and this is what you obtain with this kind of thing. And for the three and four part with the tuberative base fixation and the locking technology, we are able also to reconstruct the proximal humerus nicely as you can see here on this example here. So for us, we have totally abandoned the plate for the treatment of two, three and four part fractures. Finally, the adventure of the software was another big adventure and it started with my meeting with Jean Chahui in Paris some years ago and we started to work on the planification and navigation together with Gilles Vache and we developed this surgical planning software which was based on automatic segmentation and which allowed 3D reconstructions, 3D measurements, virtual implantation of the prosthesis, dynamic evaluation of the range of motion and possibility to develop patient-specific guide, patient-specific bone graft, patient-specific prosthesis. So this was an unbelievable adventure for us. And of course, we crossed the ocean and once again to share this with some friends that participate to the development of this software. And why using a software? For many reasons, for a strategic reason. You need to choose between the anatomic or the reverse prosthesis and artificial intelligence can do it for you. You should be a colonel having a technique and you can plan your surgery and make a trial without error. And of course, you are also a simple soldier, a technician and you need to implant your prosthesis or your graft correctly. So with optimal sizes, optimal position, optimal orientation and because you want optimal range of motion. So that's the planning that you can do and even with a very severe dysplasia of the glenoid, like in this case, you can obtain very good results. As you can see with the bio-assay here, taking a big bone graft, you can reconstruct the glenoid and six months after the surgery having this kind of results in the patient, which was not expected many years ago. So if you don't want you to use bone graft, you can use metal, of course, metal augment or metal patient specific, like in this case, where you have to build the prosthesis before you go in the OR. So it has been my 30-year odyssey through shoulder innovations and it's a life of adventure and it's a scientific, a technological, an industrial and human adventure. It has been really a human adventure with many people that we met all over the world, with many fellows, many friends all over the world who have participated and who have helped us to share our knowledge and to share the innovation that we were able to build and everything has been clearly, clearly analyzed with meetings in this, with the knee-shoulder course 1996-2001 and then every two, every of the years we did a new meeting to analyze our complications, our results regarding the development of new prosthesis. Today, we are here. The future is here. We use, we can use, we start to use mixed reality. We can use navigation, artificial intelligence, robotic, everything is here. Unfortunately, the future is not here for everybody and we should think about what we can do for less developed countries and I'm used to go in Africa for the humanitarian surgery and you can see that they can put a paracarbon hemiarthroplasty that fall in the room, in the floor of my operating room in this patient in Africa. This is something very simple that can help these patients. But my latest innovation is this one. You see, I had to put a reverse prosthesis in a patient to do a bi-RSA in fact and I realized that I didn't have any instrumentation to do the procedure. That's why I modified this fork to be able to screw, to tighten the screw of the base plate of the reverse prosthesis and to compress the ball grab. So sometimes innovation can be very simple and can also be used in surgery and help people with less money that we have in the developed countries. This was really one of the first bi-RSA implanted in Africa in this case and we should think, I believe, to develop less costly procedure and less costly implants for those countries. Thank you very much and I hope to see you next June in Nice on June 6, 7 and 8, 2024. We will do another shoulder course and the theme of the meeting is necessary versus unnecessary surgery. So this should be really fun because as you know, as you realize, in shoulder surgery we see many more operations to do today, but some of them appears to be probably unnecessary and we have to clear this situation. We cannot continue like this. So that's what the goal of this meeting is and I hope to see you there. Thank you very much. Thanks very much to Pascal for being willing to narrate that for us as we go through. As you can see, an astonishing career in all kinds of areas. I think when I finished my training 25-27 years ago, the shoulder was sort of in its renaissance. There were so many undiscovered. Think about it. We didn't have we didn't have anything such as a reverse shoulder arthroplasty. We didn't have planning navigation. There were so many unanswered questions and the box has begun to be opened.

shoulder surgery

arthroscopy

arthroplasty

fractures

software

innovations